Pre-excitation pacing for treatment of hypertension

ABSTRACT

Described herein are methods and apparatus for treating hypertension with electrical pre-excitation pacing therapy. Electrical pre-excitation of a hypertrophic region advances the timing of the regional contraction and reduces its contribution to the overall contraction. Such pre-excitation pacing therapy may be beneficial to hypertensive patients with an abnormal distribution of ventricular wall stress/strain.

CLAIM OF PRIORITY

This application is a continuation of and claims the benefit of priorityunder 35 U.S.C. §120 to U.S. patent application Ser. No. 13/279,503,filed on Oct. 24, 2011, which is a division of and claims the benefit ofpriority under 35 U.S.C. §120 to U.S. patent application Ser. No.11/557,202, filed on Nov. 7, 2006, now issued as U.S. Pat. No.8,046,070, each of which is hereby incorporated by reference herein inits entirety.

FIELD OF THE INVENTION

This invention pertains to cardiac rhythm management devices such aspacemakers and other implantable devices.

BACKGROUND

Hypertension is abnormally high blood pressure and is one of the mostcommon diseases afflicting humans. If left untreated, hypertension leadsto multiple organ damage and is associated with much morbidity andmortality worldwide. Hypertension is an important risk factor forcoronary heart disease, stroke, congestive heart failure, end-stagerenal disease, and peripheral vascular disease.

Hypertension is defined with respect to systolic and/or diastolicpressure and may be either essential or secondary. Essentialhypertension is hypertension where there is no identifiable secondarycause. Approximately 95% of American adults with hypertension haveessential hypertension, while secondary hypertension accounts for fewerthan 5% of the cases. The pathogenesis of essential hypertension iscomplex, and the factors involved may vary from patient to patient. Suchfactors could include, for example, abnormalities in blood vesselelasticity or resistance, cardiac output, circulating blood volume, andcirculating hormone levels. Hypertension is most commonly treated bylifestyle modifications (e.g., diet and exercise) and variouspharmacological agents. These treatments are not always effective incertain patients, however, and blood pressure medications are notwithout significant side effects.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates the physical configuration of an exemplary pacingdevice.

FIG. 2 shows the components of an exemplary device.

FIG. 3 is a block diagram of the electronic circuitry of an exemplarydevice.

FIG. 4 illustrates an exemplary algorithm for duty cycling thepre-excitation state.

FIG. 5 illustrates another exemplary algorithm for duty cycling thepre-excitation state.

DETAILED DESCRIPTION

When arterial blood pressure becomes elevated, the mechanical load thatthe heart must pump against, termed the afterload, is increased. Thecompensatory response of the heart to the increased afterload ishypertrophy, allowing the heart to pump more strongly against theelevated pressure. Although the hypertrophy may at first allow cardiacoutput to remain normal, it eventually causes various aberrations inventricular function that lessen cardiac output and can progress tocongestive heart failure. Left ventricular hypertrophy due tolong-standing hypertension most commonly leads to diastolic dysfunctionwhere the hypertrophic left ventricle is poorly compliant and does notrelax normally during diastole, thus causing lessened diastolic fillingand stroke volume. Studies have shown that patients with bothhypertension and diastolic filling abnormalities exhibit an abnormaldistribution of cardiac wall strain and stress. In most of thesepatients, the interventricular septum is both hypertrophic andmechanically delayed during contraction, causing it to contributeinordinately to the overall contraction. In other patients, a region ofhypertrophy elsewhere may be mechanically delayed and similarly cause anabnormal strain/stress distribution in the ventricular wall. Theabnormal contraction pattern of the ventricle produced by the regionalhypertrophy causes a pressure waveform during systole that is moresharply peaked than normal. The result is in an increased peak pulsepressure and/or mean systolic blood pressure. Similar contractionpatterns may also occur in patients who are hypertensive but not yet indiastolic heart failure.

Described herein are methods and apparatus for treating hypertensionwith electrical pre-excitation pacing therapy. As explained below,electrical pre-excitation of a hypertrophic region advances the timingof the regional contraction and reduces its contribution to the overallcontraction. This may cause both an increase in stroke volume and aconcomitant drop in systolic blood pressure. Such pre-excitation pacingtherapy may be beneficial to hypertensive patients with an abnormaldistribution of ventricular wall stress/strain, whether or nor they alsohave overt diastolic heart failure. Patients with hypertension who arenot in heart failure often have similar underlying strain abnormalitiesthat lead to the hypertrophy and diastolic filling abnormalities presentin the patients with symptomatic heart failure. By treating theseabnormalities early, it may be possible to halt or at least slow theprogression to heart failure.

Pre-excitation pacing may be delivered by an implantable device thatdelivers electrical stimulation, for example, to the left ventricularseptum (or other hypertrophic region) by an electrode positioned eitherin a coronary vein or elsewhere adjacent the ventricular septum. Thedevice may incorporate multiple pacing electrodes from which one or moremay be selected to fit different strain distributions. The timing of thestimulation with respect to atrial activation may be adjusted to reduceblood pressure while increasing or maintaining stroke volume. In oneembodiment, the amount and/or timing of the stimulation may becontrolled in a closed-loop fashion by means of a blood pressure and/orcardiac output sensor.

Pre-Excitation Pacing

The degree of tension on a muscle fiber before it contracts is termedthe preload, while the degree of tension on a muscle fiber as itcontracts is termed the afterload. Increasing the preload stretches amuscle fiber and also increases its maximum tension and velocity ofshortening during contraction. With respect to the heart, the preload ofa particular myocardial region is the myocardial wall stress at the endof diastole due to end-diastolic pressure and the forces applied byadjacent regions. The afterload of a myocardial region is the myocardialwall stress during systole due to the pressure load that the heart mustpump against. When a myocardial region contracts late relative to otherregions, the contraction of those other regions stretches the latercontracting region and increases its preloading, thus causing anincrease in the contractile force generated by the region. Conversely, amyocardial region that contracts earlier relative to other regionsexperiences decreased preloading and generates less contractile force.Because pressure within the ventricles rises rapidly from a diastolic toa systolic value as blood is pumped out into the aorta and pulmonaryarteries, the parts of the ventricles that contract earlier duringsystole do so against a lower afterload than do parts of the ventriclescontracting later. Thus, if a hypertrophic ventricular regionresponsible for an abnormally high pulse pressure can be made tocontract earlier than other parts of the ventricle, it will be subjectedto both a decreased preload and afterload. The region will then contractwith less velocity and force during systole to result in decreased pulsepressure.

In order to cause early contraction and lessened stress,electro-stimulatory pacing pulses may be delivered to one or more sitesin or around a hypertrophic region in a manner that pre-excites thosesites relative to the rest of the ventricle. (As the term is usedherein, a pacing pulse is any electrical stimulation of the heart ofsufficient energy to initiate a propagating depolarization, whether ornot intended to enforce a particular heart rate.) In a normal heartbeat,the specialized His-Purkinje conduction network of the heart rapidlyconducts excitatory impulses from the sino-atrial node to theatrio-ventricular node, and thence to the ventricular myocardium toresult in a coordinated contraction of both ventricles. Artificialpacing with an electrode fixed into an area of the myocardium does nottake advantage of the heart's normal specialized conduction system forconducting excitation throughout the ventricles because the specializedconduction system can only be entered by impulses emanating from theatrio-ventricular node. Thus the spread of excitation from a ventricularpacing site must proceed only via the much slower conducting ventricularmuscle fibers, resulting in the part of the ventricular myocardiumstimulated by the pacing electrode contracting well before parts of theventricle located more distally to the electrode.

Pre-excitation of a paced site relative to other sites can be used todeliberately change the distribution of wall stress experienced by theventricle during the cardiac pumping cycle. Pacing therapy to unload ahypertrophic ventricular region may be implemented by pacing theventricles at a single site in proximity to the hypertrophic region orby pacing at multiple ventricular sites in such proximity. In the lattercase, the pacing pulses may be delivered to the multiple sitessimultaneously or in a defined pulse output sequence. The single-site ormultiple site pacing may be performed in accordance with a bradycardiapacing algorithm such as an inhibited demand mode or a triggered mode.

Exemplary Implantable Device

FIG. 1 shows an implantable cardiac device 100 for deliveringpre-excitation pacing therapy to a hypertrophic region as well aspossibly other types of pacing therapy. Implantable pacing devices (alsoreferred to herein as pacemakers, regardless of other functions thatsuch devices may perform) are typically placed subcutaneously orsubmuscularly in a patient's chest with leads threaded intravenouslyinto the heart to connect the device to electrodes disposed within aheart chamber that are used for sensing and/or pacing of the chamber.Electrodes may also be positioned on the epicardium by various means. Aprogrammable electronic controller causes the pacing pulses to be outputin response to lapsed time intervals and/or sensed electrical activity(i.e., intrinsic heart beats not as a result of a pacing pulse). Thedevice senses intrinsic cardiac electrical activity through one or moresensing channels, each of which incorporates one or more of theelectrodes. In order to excite myocardial tissue in the absence of anintrinsic beat, pacing pulses with energy above a certain threshold aredelivered to one or more pacing sites through one or more pacingchannels, each of which incorporates one or more of the electrodes. FIG.1 shows the exemplary device having two leads 200 and 300, each of whichis a multi-polar (i.e., multi-electrode) lead having electrodes 201-203and 301-303, respectively. The electrodes 201-203 are disposed in theright ventricle in order to excite or sense right ventricular or septalregions, while the electrodes 301-303 are disposed in the coronary sinusor cardiac veins in order to excite or sense regions of the leftventricle. Other embodiments may use any number of electrodes in theform of unipolar and/or multi-polar leads in order to excite differentmyocardial sites. As explained below, once the device and leads areimplanted, the pacing and/or sensing channels of the device may beconfigured with selected ones of the multiple electrodes in order toselectively pace or sense a particular myocardial site(s).

FIG. 2 shows the components of the implantable device 100 in more detailas well as an exemplary monitoring/programming system. The implantabledevice 100 includes a hermetically sealed housing 130 that is placedsubcutaneously or submuscularly in a patient's chest. The housing 130may be formed from a conductive metal, such as titanium, and may serveas an electrode for delivering electrical stimulation or sensing in aunipolar configuration. A header 140, which may be formed of aninsulating material, is mounted on the housing 130 for receiving leads200 and 300 which may be then electrically connected to pulse generationcircuitry and/or sensing circuitry. Contained within the housing 130 isthe electronic circuitry 132 for providing the functionality to thedevice as described herein which may include a power supply, sensingcircuitry, pulse generation circuitry, a programmable electroniccontroller for controlling the operation of the device, and a telemetrytransceiver capable of communicating with an external programmer or aremote monitoring device 190. An external programmer wirelesslycommunicates with the device 100 and enables a clinician to receive dataand modify the programming of the controller. A remote monitoring devicealso communicates via telemetry with the device 100 and may be furtherinterfaced to a network 195 (e.g., an internet connection) forcommunicating with a patient management server 196 that allows clinicalpersonnel at remote locations to receive data from the remote monitoringdevice as well as issue commands. The controller may be programmed suchwhen particular conditions are detected by the monitoring circuitry(such as when a measured parameter exceeds or falls below a specifiedlimit value), the device transmits an alarm message to the remotemonitoring device and to the patient management server to alert clinicalpersonnel.

A block diagram of the circuitry 132 is illustrated in FIG. 3. A battery22 supplies power to the circuitry. The controller 10 controls theoverall operation of the device in accordance with programmedinstructions and/or circuit configurations. The controller may beimplemented as a microprocessor-based controller and include amicroprocessor and memory for data and program storage, implemented withdedicated hardware components such as ASICs (e.g., finite statemachines), or implemented as a combination thereof. The controller alsoincludes timing circuitry such as external clocks for implementingtimers used to measure lapsed intervals and schedule events. As the termis used herein, the programming of the controller refers to either codeexecuted by a microprocessor or to specific configurations of hardwarecomponents for performing particular functions. Interfaced to thecontroller are sensing circuitry 30 and pulse generation circuitry 20 bywhich the controller interprets sensing signals and controls thedelivery of paces in accordance with a pacing mode. The sensingcircuitry 30 receives atrial and/or ventricular electrogram signals fromsensing electrodes and includes sensing amplifiers, analog-to-digitalconverters for digitizing sensing signal inputs from the sensingamplifiers, and registers that can be written to for adjusting the gainand threshold values of the sensing amplifiers. The pulse generationcircuitry 20 delivers pacing pulses to pacing electrodes disposed in theheart and includes capacitive discharge pulse generators, registers forcontrolling the pulse generators, and registers for adjusting pacingparameters such as pulse energy (e.g., pulse amplitude and width). Thedevice allows adjustment of the pacing pulse energy in order to ensurecapture of myocardial tissue (i.e., initiating of a propagating actionpotential) by a pacing pulse. The pulse generation circuitry may alsoinclude a shocking pulse generator for delivering adefibrillation/cardioversion shock via a shock electrode upon detectionof a tachyarrhythmia. A telemetry transceiver 80 is interfaced to thecontroller which enables the controller to communicate with an externalprogrammer and/or a remote monitoring unit. The telemetry transceivermay also be used to wirelessly connect the implantable device to anexternal sensor such as for measuring blood pressure. A magnetically ortactilely actuated switch 24 is also shown as interfaced to thecontroller to allow the patient to signal certain conditions or eventsto the implantable device.

A pacing channel is made up of a pulse generator connected to anelectrode, while a sensing channel is made up of a sense amplifierconnected to an electrode. Shown in the figure are electrodes 40 ₁through 40 _(N) where N is some integer. The electrodes may be on thesame or different leads and are electrically connected to a MOS switchmatrix 70. The switch matrix 70 is controlled by the controller and isused to switch selected electrodes to the input of a sense amplifier orto the output of a pulse generator in order to configure a sensing orpacing channel, respectively. The device may be equipped with any numberof pulse generators, amplifiers, and electrodes that may be combinedarbitrarily to form sensing or pacing channels. The switch matrix 70allows selected ones of the available implanted electrodes to beincorporated into sensing and/or pacing channels in either unipolar orbipolar configurations. A bipolar sensing or pacing configuration refersto the sensing of a potential or output of a pacing pulse between twoclosely spaced electrodes, where the two electrodes are usually on thesame lead (e.g., a ring and tip electrode of a bipolar lead or twoselected electrodes of a multi-polar lead). A unipolar sensing or pacingconfiguration is where the potential sensed or the pacing pulse outputby an electrode is referenced to the conductive device housing oranother distant electrode.

The device illustrated in FIG. 3 may be configured with multiple sensingand/or pacing channels that may be either atrial or ventricular channelsdepending upon the location of the electrode. The device is thereforecapable of delivering single-site or multiple site ventricularpre-excitation pacing for purposes of treating hypertension as well asconventional pacing. The switch matrix allows particular myocardialsites to be pre-excited by selecting the appropriately disposedelectrode(s) to be incorporated into a pacing channel used to deliverpre-excitation pacing. Configuration of pacing and sensing channels maybe performed via an external programmer communicating through thetelemetry interface or, as discussed below, may be performedautomatically by the controller executing a configuration algorithm.

Pre-excitation pacing may be delivered as single-site pacing,biventricular pacing where one of the ventricles is pre-excited relativeto the other as determined by a programmed biventricular offsetinterval, or delivered as multi-site ventricular pacing. In the casewhere the pre-excitation pacing is delivered at multiple sites, thesites may be paced simultaneously or in accordance with a particularpulse output sequence that specifies the order and timing in which thesites are to be paced during a single beat. When an electrogram signalin an atrial or ventricular sensing channel exceeds a specifiedthreshold, the controller detects an atrial or ventricular sense,respectively, which pacing algorithms may employ to trigger or inhibitpacing. The controller is capable of operating the device in a number ofprogrammed modes where a programmed mode defines how pacing pulses areoutput in response to sensed events and expiration of time intervals.Pre-excitation pacing of one or more ventricular sites may be deliveredin conjunction with a bradycardia pacing mode, which refers to a pacingalgorithm that enforces a certain minimum heart rate, and may include ornot include pacing pulses delivered to the atria or ventricles for otherpurposes (e.g., treatment of bradycardia). Inhibited demand bradycardiapacing modes utilize escape intervals to control pacing in accordancewith sensed intrinsic activity. In an inhibited demand ventricularpacing mode, the ventricle is paced during a cardiac cycle only afterexpiration of a defined escape interval during which no intrinsic beatby the chamber is detected. For example, a ventricular escape intervalcan be defined between ventricular events so as to be restarted witheach ventricular sense or pace, referred to as lower rate interval(LRI). The inverse of this escape interval is the minimum rate at whichthe pacemaker will allow the ventricles to beat, sometimes referred toas the lower rate limit (LRL). Paces may also be delivered in arate-adaptive pacing mode where the lower rate interval and/or otherescape intervals are modified in accordance with a measured exertionlevel such as with accelerometer 26 or minute ventilation sensor 25. Inatrial tracking and AV sequential pacing modes, another ventricularescape interval is defined between atrial and ventricular events,referred to as the atrio-ventricular interval (AVI) or AV delayinterval. The atrio-ventricular interval is triggered by an atrial senseor pace and stopped by a ventricular sense or pace. A ventricular paceis delivered upon expiration of the atrio-ventricular interval if noventricular sense occurs before the expiration. Multi-site pacing modesmay use other pacing parameters that specify the timing of pacing pulsessuch as a VV delay interval that specifies the timing between pacesdelivered to both ventricles or different sites in the same ventricle.

Also shown in FIG. 3 as communicating with the controller are a pressuresensor 91 and a cardiac output sensor 92. As explained below, in oneembodiment, either or both of these sensors may be used for automaticconfiguration of pre-excitation pacing channels, closed-loop control ofthe amount of pre-excitation pacing, and/or closed-loop control oftiming parameters. Either or both of the sensors may be incorporatedinto leads that are intravascularly disposed or may be external devicesthat communicate with the controller wirelessly via telemetry. Thepressure sensor 91 and cardiac output sensor 92 generate signals thatare related to a patient's blood pressure and cardiac output,respectively, and may be any type of transducers for those purposes. Thecardiac output sensor 92, for example, could be a flow sensor or animpedance sensor for measuring cardiac volumes such as end-diastolicfilling volume.

Delivery of Anti-Hypertension Pre-Excitation Pacing

As described above, some hypertensive patients exhibit abnormalstress/strain distributions in the left ventricle during systole due toa late-contracting, hypertrophied region of the ventricle. Thehypertrophied region in these patients may thus contribute inordinatelyto the contraction and cause an abnormal systolic pressure waveform.Such an abnormal systolic pressure may cause or contribute to thepatient's hypertension. By pre-excitation of the hypertrophied region orregions with pacing pulses, the region may be made to contract earlierduring systole in order to at least partially normalize thestress/strain distribution and resulting systolic pressure waveform,thereby reducing the patient's hypertension. The more normal systolicpressure waveform may also result in an improved cardiac output.

Hypertensive patients most likely to benefit from pre-excitation pacingtherapy may be identified, for example, with clinical studies thatdemonstrate an abnormal left ventricular systolic pressure waveform,abnormal contraction pattern, and/or region(s) of hypertrophy. Apacemaker is then implanted with one or more pacing electrodes disposednear the hypertrophied region so as to provide the desiredpre-excitation. The pacemaker may be programmed to deliver theventricular pre-excitation pacing in accordance with a bradycardiapacing mode such as an atrial tracking or AV sequential mode. Variablessuch as cardiac output and/or blood pressure may also be measured andtaken into account in order to optimally select pre-excitation pacingsites and/or pacing parameter values (e.g., AV and VV delay intervals).For example, the AV delay interval may be adjusted for atrial trackingor AV sequential modes to a value that optimizes ventricular filling andresulting cardiac output. Different pre-excitation pacing sites may betested, either by changing lead implant sites or by reconfiguring pacingchannels after implantation, while the patient's blood pressure ismeasured in order to determine the site(s) for delivering pre-excitationpacing that optimally reduces systolic blood pressure. The patient mayalso be challenged with a drug that raises blood pressure while testingdifferent pacing sites and/or pacing parameter values for efficacy inlowering blood pressure. As described below, a pacemaker may also beconfigured to automatically determine pre-excitation pacing sites and/orpacing parameters based upon sensor measurement.

As noted, some patients may experience an improvement in cardiac outputfrom pre-excitation due to normalization of the systolic pressurewaveform. In these patients, the pacemaker may be programmed to deliverpre-excitation pacing on a continuous basis similar to the way mostpacemaker patients are treated for bradycardia. In other patients,cardiac output may be lessened somewhat as systolic pressure is reducedby the pre-excitation pacing. In this group of patients, it may bedesirable for the pre-excitation pacing to be delivered intermittently.The pacemaker could then be programmed to deliver pre-excitation pacingin accordance with a programmed pre-excitation pacing mode only when thedevice is operating in a pre-excitation state, where the pre-excitationstate is duty cycled. The pacemaker could then duty cycle thepre-excitation state in accordance with a schedule based upon lapsedtime intervals and/or in accordance with sensed events or conditions.For example, the pre-excitation state may be entered only at certaintimes of the day (e.g., at night) and for specified durations. Inanother example, the pacemaker is equipped with an exertion level sensor(e.g., an accelerometer for measuring activity or a minute ventilationsensor for measuring respiration) and be programmed to enter or exit thepre-excitation state if the patient's measured exertion level withinsome specified range. In a chronotropically competent patient, heartrate may be used in a similar manner as exertion level to controlentering or exiting the pre-excitation state. As described below, thepacemaker could also be configured with the capability of measuringblood pressure and/or cardiac output to enable closed-loop duty cyclingof the pre-excitation state based upon those variables.

Closed-Loop Control of Anti-Hypertension Pre-Excitation Pacing

As shown in FIG. 3, an implantable pacing device for deliveringpre-excitation pacing to treat hypertension may be equipped with sensorsfor measuring variables related to blood pressure and/or cardiac output.The blood pressure and/or cardiac output measurements thereby obtainedmay be instantaneous measurements or may be averages taken over somespecified period of time. As described below, the device may beprogrammed to control anti-hypertension pre-excitation pacing in aclosed-loop manner by varying the duty cycle of the pre-excitationstate, varying pre-excitation pacing parameters such as the AV delayinterval or pacing mode, and/or automatically configuring pre-excitationpacing channels in accordance with such blood pressure and/or cardiacoutput measurements.

In an exemplary embodiment, an implantable pacing device is configuredwith one or more pre-excitation pacing channels that include pulsegenerating circuitry and one or more electrodes adapted for dispositionnear one or more myocardial sites. The device controller is programmedto deliver paces through the pre-excitation pacing channel(s) inaccordance with a programmed pre-excitation pacing mode when the deviceis operating in a pre-excitation state. For example, the controller canbe programmed to deliver pre-excitation pacing as ventricular pacing inaccordance with an atrial tracking or AV sequential pacing mode suchthat one or more pre-excitation paces are delivered upon expiration of aprogrammed AV delay interval following an atrial sense When the deviceis in a non-pre-excitation state, it may deliver no pacing therapy atall or may deliver pacing therapy for another purpose (e.g., bradycardiapacing) using a pacing site or mode other than that used forpre-excitation pacing. The device further includes a blood pressuresensor communicating with the controller for generating a signal relatedto a patient's arterial blood pressure, the controller being programmedto derive a blood pressure measurement therefrom. The blood pressuremeasurement may be derived instantaneously from the blood pressuresignal or be derived from an average of the blood pressure signalpressure as generated over a specified period of time. The controller isthen programmed to duty cycle the pre-excitation state such that theamount of pre-excitation pacing delivered by the device is increased ifthe blood pressure measurement increases to a specified extent. Thedevice may also incorporate a cardiac output sensor for measuring avariable related to a patient's cardiac output. The controller can thenbe programmed to adjust the AV delay interval used during pre-excitationpacing in a manner that maximizes the value of the cardiac outputmeasurement.

In one embodiment, the controller is programmed to duty cycle thepre-excitation state by entering the pre-excitation state if the bloodpressure measurement is above a first limit value and exiting thepre-excitation state if the blood pressure measurement is below a secondlimit value, where the first and second limit values may be the same ordifferent. FIG. 4 illustrates an exemplary algorithm that could beexecuted by the controller to implement such duty cycling. The algorithmbegins after the device has exited the pre-excitation (PE) state and isin a non-pre-excitation state where no pre-excitation pacing is beingdelivered. At step 401, the device obtains a blood pressure measurementBP. At step 402, the blood pressure measurement is compared with a firstlimit value LV1. The device continues to monitor blood pressure while inthe non-PE state. When the blood pressure measurement rises above thefirst limit value, the device enters the PE state at step 403 anddelivers pre-excitation pacing. At step 404, a blood pressuremeasurement is again obtained. At step 405, the blood pressuremeasurement is compared with a second limit value LV2. The devicecontinues to monitor blood pressure while delivering pre-excitationpacing in the PE state. When the blood pressure measurement falls belowthe second limit value, the PE state is exited at step 406, and thedevice returns to step 401.

In another embodiment, the controller is programmed to duty cycle thepre-excitation state by entering and exiting the pre-excitation state inaccordance with a schedule based upon lapsed time intervals and furtherprogrammed to modify the schedule to increase the duration of thepre-excitation state if the blood pressure measurement increases to somespecified extent. FIG. 5 illustrates an exemplary algorithm that couldbe executed by the controller to implement such duty cycling. Thealgorithm begins after the device has exited the pre-excitation (PE)state and is in a non-pre-excitation state where no pre-excitationpacing is being delivered. At step 501, a duty cycle timer is startedwhich counts from zero to T minutes (or other unit of time) where T issome specified value. At step 502, the device enters the PE state andbegins delivering pre-excitation pacing. At step 503, while continuingto operate in the PE state, the device monitors the duty cycle timeruntil M minutes have elapsed, at which point the device exits the PEstate at step 504. The device monitors the duty cycle timer at step 505until T minutes have elapsed and then obtains a blood pressuremeasurement BP at step 506. The value of M (i.e., the number of minutesfor which the device operates in the pre-excitation state out of every Tminutes) is then calculated as a function of the blood pressuremeasurement BP at step 507. The function for mapping the blood pressuremeasurement to a value for M could be simple, such as where the value ofM alternates between two values according to the value of the bloodpressure measurement, or more complicated. In the latter instance, thefunction could be implemented as a look-up table.

The device may also be configured to use one or more entry and/or exitconditions in controlling entry and/or exit into the PE state. An entryor exit condition could be, for example, specified time(s) of the day,actuation of a switch by the patient (e.g., a magnetically or tactilelyactuated switch interfaced to the device controller), a command receivedvia telemetry, or a measured variable being within or out of a specifiedrange. Examples of such measured variables include heart rate, activitylevel, minute ventilation, cardiac output, and blood pressure. Aplurality of entry and/or exit conditions may also be logically ORed orANDed together to determine whether a composite entry or entry conditionis satisfied. In some embodiments, the device may be programmed tosimply enter and/or exit the PE state in accordance with one or morespecified entry or exit conditions. In other embodiments, one or morespecified entry and/or exit conditions are used to permit and/orprohibit, respectively, duty cycling of the PE state such as describedabove with reference to FIGS. 4 and 5 or other duty cycling schemesbased upon lapsed time intervals and/or a sensed variables such as bloodpressure and cardiac output.

The device may also incorporate a switching matrix operable by thecontroller for configuring pacing channels with selected pacingelectrodes. The controller may be programmed to periodically reconfigurethe pre-excitation pacing channel(s) with a different selected pacingelectrode in order prevent hypertrophy from developing at a regionexcited later during systole as a result of pre-excitation pacing. Forexample, the device could periodically switch between right ventricularpacing and left ventricular pacing. The controller could also beprogrammed to optimally configure the pre-excitation pacing channel(s)by sequentially reconfiguring the pre-excitation pacing channel(s) withdifferent pacing electrodes and selecting the pacing electrode for usein the pre-excitation pacing channel(s) that results in the greatestdecrease in the blood pressure measurement. The controller may befurther programmed to sequentially test different pacing modes (e.g.,right ventricular, left ventricular, biventricular, or multi-siteventricular pacing) and/or pacing parameters (e.g., AV delay interval,VV delay interval) and to select the pacing mode and/or parameter foruse in the pre-excitation state that results in the greatest decrease inthe blood pressure measurement. A cardiac output measurement could becombined with the blood pressure measurement in configuring pacingchannels, selecting pacing modes, and/or adjusting pacing parameters inorder to optimize both blood pressure reduction and cardiac outputimprovement.

The invention has been described in conjunction with the foregoingspecific embodiments. It should be appreciated that those embodimentsmay also be combined in any manner considered to be advantageous. Also,many alternatives, variations, and modifications will be apparent tothose of ordinary skill in the art. Other such alternatives, variations,and modifications are intended to fall within the scope of the followingappended claims.

1. A method, comprising: identifying a patient as having hypertension;implanting a pacemaker in the patient; selecting a pacing mode, one ormore pacing sites, and pacing parameter values to deliver pre-excitationpacing that optimally decrease the patient's blood pressure.
 2. Themethod of claim 1 further comprising measuring the patient's cardiacoutput and selecting a pacing mode, one or more pacing sites, and pacingparameter values that optimally decrease the patient's blood pressurewhile maintaining adequate cardiac output.
 3. The method of claim 1further comprising programming the pacemaker to deliver pre-excitationpacing intermittently according to a defined schedule.
 4. The method ofclaim 1 further comprising programming the pacemaker to deliverpre-excitation pacing intermittently in accordance with whether ameasured heart rate is within or outside of a specified range.
 5. Themethod of claim 1 further comprising programming the pacemaker todeliver pre-excitation pacing intermittently in accordance with whethera measured activity level is within or outside of a specified range. 6.The method of claim 1 further comprising programming the pacemaker todeliver pre-excitation pacing intermittently in accordance with whethera measured activity level is within or outside of a specified range. 7.The method of claim 1 further comprising challenging the patient with adrug that raises blood pressure while testing different pacing sitesand/or pacing parameter values for efficacy in lowering blood pressure.8. The method of claim 1 further comprising providing the patient with ameans for stopping or starting pre-excitation pacing.
 9. The method ofclaim 1 further comprising optimally configuring a pacing channel of thepacemaker by sequentially reconfiguring the pacing channel withdifferent pacing electrodes and selecting the pacing electrode for usein the pacing channel that results in the greatest decrease in the bloodpressure measurement during delivery of pre-excitation pacing.
 10. Animplantable pacing device, comprising: pulse generating circuitry foroutputting pacing pulses through one or more pre-excitation pacingchannels; a controller programmed to deliver paces through thepre-excitation pacing channel(s) in accordance with a programmedpre-excitation pacing mode when the device is operating in apre-excitation state; wherein the controller is operable to configurethe pre-excitation pacing channel(s) with a pacing electrode selectedamong a plurality of pacing electrodes; a blood pressure sensorcommunicating with the controller for generating a signal related to apatient's arterial blood pressure, the controller being programmed toderive a blood pressure measurement therefrom; wherein the controller isprogrammed to duty cycle the pre-excitation state by entering thepre-excitation state if the blood pressure measurement is above a firstlimit value and exiting the pre-excitation state if the blood pressuremeasurement is below a second limit value.
 11. The device of claim 10wherein the controller is programmed to optimally configure thepre-excitation pacing channel(s) by sequentially reconfiguring thepre-excitation pacing channel(s) with different pacing electrodes andselecting the pacing electrode for use in the pre-excitation pacingchannel(s) that results in the greatest decrease in the blood pressuremeasurement during delivery of pre-excitation pacing
 12. The device ofclaim 10 wherein the controller is programmed to duty cycle thepre-excitation state by entering and exiting the pre-excitation state inaccordance with a schedule based upon lapsed time intervals and whereinthe controller is further programmed to modify the schedule to increasethe duration of the pre-excitation state if the blood pressuremeasurement increases to the specified extent.
 13. The device of claim10 wherein the blood pressure measurement is an average of the signalrelated to a patient's arterial blood pressure as generated over aspecified period of time.
 14. The device of claim 10 further comprisingan exertion level sensor for measuring a variable related to a patient'sexertion level and wherein the controller is programmed to exit thepre-excitation state if the exertion level measurement increases above aspecified threshold value.
 15. The device of claim 10 furthercomprising: a cardiac output sensor for measuring a variable related toa patient's cardiac output; wherein the controller is programmed todeliver pre-excitation pacing as ventricular pacing in accordance withan atrial tracking or AV sequential pacing algorithm such that one ormore pre-excitation paces are delivered upon expiration of a programmedAV delay interval following an atrial sense or pace; and, wherein thecontroller is programmed to adjust the AV delay interval duringpre-excitation pacing in a manner that is designed to maximize the valueof the cardiac output measurement.
 16. The device of claim 10 whereinthe controller is programmed to periodically reconfigure thepre-excitation pacing channel(s) with a different pacing electrode. 17.The device of claim 10 wherein the controller is further programmed tosequentially test different pacing modes and to select the pacing modefor use in the pre-excitation state that results in the greatestdecrease in the blood pressure measurement.
 18. The device of claim 17wherein the controller is further programmed to sequentially testdifferent values of one or more pacing parameters and to select valuesof the one or more pacing parameters for use in the pre-excitation statethat result in the greatest decrease in the blood pressure measurement.19. The device of claim 10 wherein the controller is further programmedto permit operation in the pre-excitation state only if a specifiedentry condition is met wherein the entry condition may be a specifiedtime of the day, actuation of a switch by the patient, a commandreceived via telemetry, or a measured variable being within or out of aspecified range where the measured variable may be heart rate, activitylevel, minute ventilation, cardiac output, or blood pressure.
 20. Thedevice of claim 10 wherein the controller is further programmed toprohibit operation in the pre-excitation state if a specified exitcondition is met wherein the exit condition may be a specified time ofthe day, actuation of a switch by the patient, a command received viatelemetry, or a measured variable being within or out of a specifiedrange where the measured variable may be heart rate, activity level,minute ventilation, cardiac output, or blood pressure.